Rev. Latino-Am. Enfermagem
Original Article
2011 July-Aug.;19(4):894-901 www.eerp.usp.br/rlae
Evaluation of the virtual learning object “Diagnostic reasoning in nursing applied to preterm newborns” Fernanda dos Santos Nogueira de Góes1 Luciana Mara Monti Fonseca2 Maria Cândida de Carvalho Furtado2 Adriana Moraes Leite2 Carmen Gracinda Silvan Scochi3
The potential use of computer technology in teaching and continuous education for nursing motivated the development of this study to evaluate the virtual learning object, “Diagnostic Reasoning in Nursing Applied to Preterm Newborns” at an intermediate neonatal care unit. This descriptive study evaluates the appearance and content of the virtual object concerning aspects related to presentation, organization, usability and overall impression. Experts from the fields of computer technology (12) and nursing (31) participated in the evaluation process. Each sub-item of the instrument was assessed on a Likert scale and blank space was provided for comments/ suggestions. All items were positively evaluated by over 80% of the experts, except for the ‘informational density’ criterion in the evaluation performed by computer technology experts. The developed product is considered adequate to be used for teaching for nursing students and in continuous education of diagnostic reasoning in the development of Nursing Diagnoses for preterm newborns, in the problem-posing pedagogical framework. Descriptors: Neonatal Nursing; Infant, Premature; Nursing Diagnosis; Computer-Assisted Instruction.
1
RN, Doctoral Student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
2
RN, Ph.D. in Nursing, Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for
Development, SP, Brazil. E-mail:
[email protected]. Nursing Research Development, SP, Brazil. E-mail: Luciana -
[email protected], Maria Cândida -
[email protected], Adriana -
[email protected]. 3
RN, Ph.D. in Nursing, Full Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, SP, Brazil. E-mail:
[email protected].
Corresponding Author: Carmen Gracinda Silvan Scochi Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto Departamento Materno-Infantil e Saúde Pública Av. dos Bandeirantes, 3900 Bairro: Monte Alegre CEP: 14040-902, Ribeirão Preto, SP, Brasil E-mail:
[email protected]
895 Avaliação do objeto virtual de aprendizagem “Raciocínio diagnóstico em enfermagem aplicado ao prematuro” Vislumbrando o potencial de uso da informática, na formação e educação permanente em enfermagem, realizou-se o presente estudo com o objetivo de avaliar objeto virtual de aprendizagem raciocínio diagnóstico em enfermagem aplicado ao prematuro, em unidade de cuidado intermediário neonatal. Trata-se de estudo descritivo sobre a avaliação da aparência e conteúdo do objeto virtual, nos aspectos relacionados à apresentação, organização, usabilidade e impressão geral. Participaram peritos das áreas de informática (12) e enfermagem (31). Cada subitem dos instrumentos continha avaliação em escala Likert e espaço para inclusão de comentários/sugestões. Todos os itens foram avaliados positivamente por mais de 80% dos avaliadores, exceto o critério densidade informacional na avaliação dos profissionais de informática. Considera-se que o produto desenvolvido está adequado para ser disponibilizado para uso no ensino de estudantes e educação permanente de enfermeiros, sobre raciocínio diagnóstico na elaboração de diagnósticos de enfermagem, aplicados ao prematuro, inserido no referencial pedagógico da problematização. Descritores: Enfermagem Neonatal; Prematuro; Diagnóstico de Enfermagem; Instrução por Computador.
Evaluación del objeto virtual de aprendizaje “Raciocinio diagnóstico en enfermería aplicado al prematuro” Vislumbrando el potencial de uso de la informática en la formación y educación permanente en enfermería, se realizó el presente estudio con el objetivo de evaluar el objeto virtual de aprendizaje “Raciocinio Diagnóstico en Enfermería Aplicado al Prematuro” en una unidad de cuidado intermedio neonatal. Se trata de un estudio descriptivo sobre la evaluación de la apariencia y contenido del objeto virtual en los aspectos relacionados a la presentación, organización, usabilidad e impresión general. Participaron peritos de las áreas de informática (12) y enfermería (31). Cada sub-ítem de los instrumentos contenía evaluación en escala tipo Likert y espacio para inclusión de comentarios/sugerencias. Todos los ítems fueron evaluados positivamente por más de 80% de los evaluadores, excepto el criterio densidad de información en la evaluación de los profesionales de informática. Se considera que el producto desarrollado está adecuado para ser colocado a disposición para uso en la enseñanza de estudiantes y en la educación permanente de enfermeros sobre raciocinio diagnóstico en la elaboración de Diagnósticos de Enfermería aplicados al prematuro, dentro del marco pedagógico de la problematización. Descriptores: Enfermería Neonatal; Prematuro; Diagnóstico de Enfermería; Instrucción por Computador.
Introduction Understanding Nursing Diagnoses as a phase
There are many definitions in the health field for
of the nursing process that involves clinical judgment
the process of making a diagnosis, such as judgment,
that corresponds to the intellectual endeavor in which
clinical reasoning and diagnostic reasoning(2), which
collected information is analyzed, judged and gathered
can be defined as the process of clinically reasoning to
to define a diagnosis, is often a difficult task for nursing
recognize relevant diagnoses, that is, a type of clinical
professionals .
reasoning aimed to establish the diagnosis that best
(1)
www.eerp.usp.br/rlae
896
Rev. Latino-Am. Enfermagem 2011 July-Aug.;19(4):894-901.
expresses the health state of individuals, families or community .
The Macromedia Authorware® is acknowledged for its precision and efficiency(6), able to gather text
(3)
A didactic resource used to enable nursing students and nurses to better understand the nursing process
and multimedia resources in a single application, thus favoring interactivity.
and diagnosis reasoning is to treat these from a linear
Up to January 2010, Moodle registered more
point of view, which however, does not allow students
than 40 million users in more than 4 million programs,
to visualize how the stages are interconnected or
demonstrating that VLE is recognized as a pedagogical
interdependent .
resource that helps students to improve cognition,
(2)
From this perspective, the search for scientific improvement to advance teaching and qualification is
construct knowledge, and promote positive attitudes through discussion and cooperation(7).
essential because the job market requires professionals
The virtual object has a modular structure with
to have knowledge to work in the systematization of
theoretical content concerning nursing diagnoses: one
nursing care(4).
module to teach diagnoses based on Risner’s work and
There is a lack of studies addressing Nursing
the NANDA taxonomy and another module containing
Diagnosis and diagnostic reasoning specifically in the field
simulations of procedures, in which seven clinical cases
of neonatal nursing care provided to preterm newborns.
of preterm infants are distributed, totaling 72 nursing
Only six studies published in the last five years focused
diagnoses.
on preterm newborns and their families.
Studies evaluating virtual objects or educational
The teaching of Nursing Diagnoses and diagnostic reasoning
in
neonatal
nursing
can
benefit
from
technology, which can help qualify competent nurses in the nursing process contributing to improved quality of care delivered to preterm newborns and their families. Because it permits the construction of repositories of classes to be accessed by various users and provide
software have not used probabilistic samples because such evaluations require that the population have defined characteristics. In relation to the number of evaluators, only one study used a sample greater than six evaluators from computer science(5) and another used a sample greater than 15 nursing scorers(8).
synchronous and asynchronous interaction tools, the
We invited 15 experts with bachelor degrees in
use of Virtual Learning Environments (VLE) can be a
computer science or related fields to identify operational
teaching strategy used in the education and qualification
errors in the system; 12 agreed to participate in the
of nurses concerning nursing diagnoses in care provided
study and signed free and informed consent forms.
to preterm newborns .
After
(5)
an
initial
evaluation
and
technical
Many authors have reported the use of VLE in
corrections in the virtual object, we proceeded to the
teaching nursing. However, only four studies used
evaluation by nursing experts. A total of 43 Brazilian
computer-based interactive resources to teach neonatal
university hospitals and 43 undergraduate nursing
nursing and none used VLE, denoting the scarcity of
programs were contacted through mail and email.
research in the field.
Of these, 29 nurses and 22 professors expressed
Hence, this study evaluated the content and
interest in participating in the evaluation of the virtual
appearance of a virtual learning object inserted into a
object in Moodle. However, only those who met the
VLE addressing diagnostic reasoning in nursing related
study criteria were included in the study: 17 nurses
to preterm infants and their families in a neonatal
and 14 professors. These criteria, contained in an
intermediate care unit.
adapted instrument, characterize expert nurses(9). The minimum score for such a characterization is 4. All the
Methods
selected raters scored between six and 11 and signed
This descriptive study reports the evaluation of a virtual interactive learning object. The project was approved by the Research Ethics Committee (Process 5229/2008). The the
virtual
object
was
multimedia-authoring
constructed tool
using
Macromedia
Authorware®, inserted into a VLE, the Moodle.
free and informed consent forms. Evaluation instruments including both the fields of technology and pedagogy were searched for critical analysis of the application and an instrument(10) was then adapted to be used by both computer and nursing professionals. This instrument has been already used by a study conducted in Brazil(11). An instrument was adapted in the form of a checklist to permit evaluating
www.eerp.usp.br/rlae
897
Góes FSN, Fonseca LMM, Furtado MCC, Leite AM, Scochi CGS. the
ergonomics
of
interface
criteria,
which
were
related to the evaluation process of the VLE. The items
included to encompass those who study technology.
that reached 70% agreement among scorers, through
Such an instrument was developed by professors from
concepts such as “agree” or “strongly agree”, according
the Federal University of Santa Catarina and made
to criterion adopted in other studies, were considered
available on the Internet(12). The instruments presented
validated(13-14).
statements concerning aspects related to the expert’s field of evaluation, a Likert-type summative method, and a blank space for suggestions. The instruments for computer science and nursing
Results Evaluation - Computer Science
were evaluated in a pilot-test by three computer
The evaluation of the interactive virtual learning
professionals and two nurses to identify potential
object “Diagnostic reasoning in nursing applied to
difficulties of understanding the terms used. These
preterm infants,” performed jointly with computer
evaluations helped clarify some of the instrument’s
science professionals, was composed of an instrument
expressions.
addressing
Data were collected between April and June 2010. The virtual learning object and respective instruments of evaluation were made available in Moodle and later sent to the researchers through email.
a
general
impression
concerning
the
presentation and organization of content (Table 1) and another addressing usability. Concerning
the
general
impression
of
the
virtual object, table 1 shows there were no negative
Descriptive statistics were used in analyzing data
evaluations.
Table 1 – Evaluation concerning general impression of the virtual object of learning – Computer field. 2010 General Impression
Criteria Agree
Strongly agree
Do not know
1. The interface of the system/virtual learning object favors learning the theme.
Strongly disagree
6 (50.0%)
5 (41.7%)
1 (8.3%)
2. Presentation of content of the system/virtual learning object favors learning the theme.
5 (41.7%)
5 (41.7%)
2 (16.6%)
3. Computer animations help learning the theme.
7 (58.3%))
5 (41.7%)
4. The system/virtual learning object is indicated to be used as an educational tool.
5 (41.7%)
6 (50.0%)
1 (8.3%)
5. The limitations of the virtual learning object do not exceed its utility in the teaching of nursing.
5 (41.7%)
5 (41.7%)
2 (16.6%)
6. I recommend the system/virtual learning object for the teaching of neonatal nursing.
5 (41.7%)
5 (41.7%)
2 (16.6%)
The following suggestions were added: There are problems with the ‘Exit’ button on some screens of the
Disagree
explicit actions 75.0%; User’s experience is considered: 75.0%, and Informational density: 66.6%.
Nursing Diagnosis module and gallery and problems
Hence, all criteria of usability of the virtual learning
going back to a previous page; Standardize fonts in the
object achieved the expected agreement (above 70%),
Nursing Diagnosis module… and …some changes related
except ‘Informational Density,’ which achieved 66.6%
to navigability are needed. All these suggestions were
due to an excess of texts necessary to construct clinical
included in the virtual object before nurses evaluated it.
cases. Four evaluators made observations concerning
The statements concerning usability were grouped into criteria, which obtained the following agreement (agree and strongly agree): Grouping by format: 100%; Quality of error messages: 100%; Speed: 97.9%;
excess of text in clinical cases, but considered the remaining modules to be adequate.
Evaluation - Nursing Field
Grouping by localization: 97.2%; Concision: 95.8%;
Given the extensive content in the virtual object,
Immediate feedback: 94.4%; Minimal actions: 91.6%;
we divided the evaluation into four groups, whose
Correction of errors: 91.7%; Consistency: 91.7%;
compositions were: Groups 1 and 4: four professors and
Compatibility: 91.7%; Readability: 89.6%; User control:
four nurses; Group 2: four professors and three nurses;
83.4%; Meaning of codes and names: 83.4%; User’s
Group 3: five professors and three nurses. The groups 1,
www.eerp.usp.br/rlae
898
Rev. Latino-Am. Enfermagem 2011 July-Aug.;19(4):894-901.
2 and 3 evaluated a case in the teaching module and one
available to all the other groups for consultation.
simulation. Group 4 evaluated a case in the simulation
After navigating through the virtual object, the
module and the theoretical content module concerning
experts answered the instruments for general impression
nursing diagnosis, though, theoretical content was
(Table 2), content (Table 3) and usability evaluations.
Table 2 – Evaluation of the general impression of virtual learning object – nursing. 2010. Criteria
General impression
Agree
Strongly agree
1. The virtual learning object is important for students learning the theme.
Strongly disagree
10 (32.3%)
21 (67.7%)
2. The interface of the virtual learning object favors learning the theme.
13 (41.9%)
18 (58.0%)
3. The content of the virtual learning object is important for learning the theme.
9 (29.0%)
22 (71.0%)
4. Computer animations help learning the theme.
Disagree
10 (32.3%)
18 (58.0%)
5. The simulation of clinical cases is relevant to learning the theme.
2 (6.4%)
10 (32.3%)
21 (67.7%)
6. The system/virtual learning object is indicated to be used as an educational tool.
9 (29.0%)
22 (71.0%)
7. The limitations of the virtual learning object are not greater than its utility.
15 (48.3%)
16 (51.6%)
Do not know
1 (3.2%)
All the items achieved 100% of agreement with exception of the item 4 (computer animation).
Table 3 – Evaluation of content of virtual learning environment – nursing. 2010 Content
Criteria Strongly disagree
Disagree
1. The objectives of the system/virtual learning object are clearly defined. 2. Content is coherent with the target-public.
1 (3.2%)
3. The virtual learning object simulates reality well.
Agree
Strongly agree
10 (32.3%)
21 (67.7%)
11 (35.5%)
19 (61.3%)
10 (32.3%)
20 (64.5%)
4. Interaction during the simulation of clinical cases is satisfactory.
2 (6.4%)
14 (45.2%)
15 (48.3%)
5. Presentation of figures is relevant to information included in the text.
1 (3.2%)
7 (22.6%)
22 (71.0%)
6. Presentation of videos is relevant to information included in the text.
2 (6.4%)
12 (38.7%)
17 (54.8%)
7. Presentation of sounds is relevant to the information included in the text.
4 (12.9%)
13 (41.9%)
14 (45.2%)
8. Virtual learning object encourages learning.
11 (35.5%)
20 (64.5%)
9. Virtual learning object permits learning based on the user’s previous experience.
16 (51.6%)
15 (48.3%)
11 (35.5%)
18 (58.0%)
10. Virtual learning object facilitates retention of content in the student’s memory.
All the items were positively evaluated with a
1 (3.2%)
Do not know
1 (3.2%)
1 (3.2%)
1 (3.2%)
Discussion
percentage above 93% of agreement. When the statements concerning the usability
We realized over the course of this study that the
criteria were grouped, the following level of agreement
use of computers in teaching nursing, specifically virtual
(agree and strongly agree) was obtained: Speed: 95%;
learning objects, has been intensified in recent years,
Readability: 92.5%; Grouping by location: 96.7%;
especially in teaching and research centers.
Consistency: 90.4%; User control: 85.5%; Immediate
The option to use Moodle facilitated the participation
feedback: 93.3%; Correction of errors: 93.6%; and
of experts from other Brazilian regions and will also
Error messages: 93.5%.
enable the dissemination of this virtual object of learning
www.eerp.usp.br/rlae
899
Góes FSN, Fonseca LMM, Furtado MCC, Leite AM, Scochi CGS. as resource aide in learning for teaching, research and
found in clinical practice and ensure appropriately
care institutions.
structured theoretical content and that reliable clinical
Some evaluators of this virtual learning object
cases are available. Clinical cases are presented in this
reported difficulties accessing Moodle. We verified that the
virtual object, allowing students to problematize real
problems were related to difficulty handling the computer
contexts(20).
and the Internet or even not reading instructions on how to execute Moodle and the interactive object. When
users
were
qualified
to
Structuring the content of virtual learning objects into modules and in a non-linear manner enables users
Moodle,
to navigate through content the way they like with
they reported positive impressions concerning the
use
flexibility, freedom respect for each one’s own rhythm,
environment and considered the platform easy to use.
and user’s can actively participate in the construction
They also manifested their intention to transform the
of their own knowledge. All these are premises of a
content of the their courses in virtual language
problem-posing education(20).
.
(15)
A limitation of this study is the proportion of
In relation to the evaluation of the virtual object’s
individuals from the nursing field who were included
usability, the great advantage in testing it lies in
in the study and did not achieve the minimum of ten
discovering problems that can represent difficulties in
evaluators per group. Nonetheless, small samples
course development(16).
composed of experts in the nursing and/or computer
We believe that the option to evaluate usability
fields have been used in studies evaluating virtual
criteria based on the criteria of the ergonomics of interface
objects or educational software in nursing(5,11,13,16).
enabled the analysis of technical aspects relevant to
analyzing interactive multimedia as a
learning. Such aspects can facilitate or hinder navigation
resource to be used in the teaching of semiology for
A study
and consequently either encourage or compromise
nursing students verified that it is medium easy to
learning. However nursing studies conducting ergonomic
use and a facilitator between theory and practice that
evaluations similar to the evaluation conducted in this
improves understanding of theoretical classes.
study were not found.
(17)
The virtual object also presents limitations that may
Only the criterion of ‘informational density’ was
in part be related to the Authorware authoring software.
considered
The construction of content in this program requires
though it was considered adequate by nurses.
inadequate
by
computer
professionals,
the creation of a structure similar to a flow chart for
Another study evaluated ergonomic criteria of a
events, tasks and decisions(18) and, during the creation
virtual environment of a clinical simulation of nursing
of this virtual object, we observed that the system was
in intensive therapy and the following were reported:
incapable of performing some necessary functions,
the organization criterion scored 4.43 (maximum was
resulting in the perception on the part of evaluators that
5); presentation scored 4.5; technical criterion related
there were deficiencies in the system, especially related
to appropriate functioning of links and download speed
to control (options to go back).
scored 4.79(11).
Another difficulty found is that it was not possible
Evaluation of VLE in another study(21) was similar to
to execute the object directly in Moodle due to the size
that of this study. Three computer experts evaluated time
of the file, even after dividing it into smaller modules.
of response, quality of interface, tools and resources,
For the evaluation to occur, it was necessary to install
educational
one executable file and send detailed instructions to the
didactic resources. Evaluations related to screen format,
experts.
error messages, ease of use, links, logical sequence of
Other
authors(19)
also
reported
limitations
aspects,
quality
of
environments
and
in
menus, icons, and informational density were considered
relation to Authorware that could not be resolved due
satisfactory or even excellent by two experts, while one
to the system’s format, which reduced possibilities of
expert considered the text, ease of use and links to be
interaction. Hence, we suggest new authoring software
regular. The comments were centered on aspects related
be used to create virtual learning objects that withstand
to clarification of navigation and instructions to execute
different levels of complexity in actions.
modules(5).
In relation to this study’s virtual object, its content
In relation to the usability of the online course
received such recommendations because it was assessed
addressing care provided to critical patients, ease of
by a group of experts in neonatology and in Nursing
navigation, quality and understanding of content were
Diagnoses to bring the user into proximity of the context
evaluated before it was distributed to students as adjuvant
www.eerp.usp.br/rlae
900
Rev. Latino-Am. Enfermagem 2011 July-Aug.;19(4):894-901.
learning material. The nurses evaluated whether the
The need to perform the last stages of implementation
course ensured active learning, feedback, interaction
provided in the adopted software is apparent: it should
of students with the course, collaboration, and whether
be evaluated by the final users.
it presented multiple resources to encourage learning.
Therefore, it is necessary to develop further studies
On a scale from 1 to 5, all the items scored from 2.63
focusing on the impact of the virtual learning object on
(collaboration) to 4.2 (resources to encourage learning),
the teaching of the nursing process and the retention
while the general evaluation of satisfaction scored 4.17,
of knowledge by undergraduate students and nurses as
which reflects great satisfaction with the course
they use it.
.
(16)
Activities mediated by computer should ensure
We conclude that the results obtained in this study
flexibility of time organization, site of study, rhythm
can contribute to the adoption of educational practices
of
and
based on the use of new computer technologies toward
object
improving the quality of nursing education and the
learning,
interaction
access .
(22)
We
to
coherent
believe
that
information
our
virtual
plays such a role since its content is available on the Internet, facilitating its access from anywhere there is network connection. The student or nurse can navigate whenever is more convenient and establish his/her own rhythm of learning. Additionally, the fact the object is not constructed in a linear manner allows the user to interact the way s/he deems appropriate with freedom of choice. From
this
perspective,
interactivity
motivates
technology users and multimedia has a prominent role in this scenario(23). Appropriate navigability is what allows users to “move” freely through the program, making the best use of information. The application of different media is frequent in educational software and increases the understanding of content(23).
Conclusion
process of qualifying nurses.
References 1.
Farias
JN.
Diagnósticos
de
enfermagem:
uma
abordagem conceitual e prática. João Pessoa: Santa Marta; 1990. 160 p. 2. Cruz DAL. Diagnósticos de enfermagem. In: Garcia TR, Egry EY, organizadores. Integralidade da atenção no SUS e sistematização da assistência de enfermagem. Porto Alegre: Artmed; 2010. 336 p. 3. Oliva APV. Banco de itens para avaliação de raciocínio diagnóstico [tese de doutorado]. São Paulo (SP): Escola de Enfermagem da Universidade de São Paulo; 2008. 84 p. 4. Cerullo JASB, Cruz DALM. Raciocínio clínico e pensamento
crítico.
Rev.
Latino-Am.
Enfermagem.
2010;18(1). [acesso 28 mar 2010]. Disponível em: http://www.scielo.br/pdf/rlae/v18n1/pt_19.pdf
doi:
10.1590/S0104-11692010000100019.
We constructed this virtual interactive learning
5. Caetano KC. Desenvolvimento e avaliação de um
object because we believe that the Nursing Process
ambiente virtual de aprendizagem em administração
within care, which in this study focused on the stage
de enfermagem [dissertação de mestrado]. São Paulo
of development of Nursing Diagnosis reasoning, coupled
(SP): Escola de Enfermagem da Universidade de São
with computer technology, has a prominent role in the
Paulo; 2006. 155 p.
qualification of nurses.
6. Kasim VM, Silva OMR. Software de autoria apoiando
Only two out of the 45 items evaluated by the
aprendizagem. 2008 [acesso 28 mar 2010]. Disponível
computer experts, which refer to informational density,
em:
failed to achieve the established 70% of agreement
educere2008/anais/pdf/640_552.pdf>.
(agree and strongly agree). All the 46 items evaluated by
7. Martín-blas T, Serrano-Fernández A. The role of
nursing professionals achieved the validation criteria.
new technologies in the learning process. Moodle as a
Hence, we assert that the developed product is
